1797_001.pdfBUITDING PERMIT
APPLICATION
DeveloPment Services
Building Division
121 slh Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements, permit status and inspection
sch ed u I i n g i nf orm atio n go to : U)Uy1gd¡ûg!.d€!g¿gQv.
PLEASE NOTE: lntake appolntments âre required for New Single Family
Resiãences, ¿orSe Additions, ADU's, New Commercial, and Moior lenant
lmprovement a[plication submittals. lf plans are prepared by a profession-
al, electronic filài are requested in addition to the hard copies.,Please bring
electron¡c files on a flash drive or coordinåte for electronic transfer'
Pteose èall 425-777-0220 to schedule an intoke oppoîntment!
n-0 Qt'Permii #:
.Jthce Use Only
JOB SITE INFORMATION/LOCATION: (\Â/here the work is taking place)
Job Site Address ' 23202 76th Ave W. Edmonds
Parcel 00576700001 709
Lot /Unit/Suite #:
-
Subdivision
PROPERW OWNER:
Name Locken Desiqner Homes lnc
Mailing Address 1 81 0 Vernon Road
city/srate/z¡p Lake Stevens WA
Phone #:425 335-3600
Email:nerhomes.com
OWNER INSTALLATION: *lf yes, read and sign*
Will work be performed by the property owner? fl Yes tr No
I own, reside in, or will reside in the completed structure. This
installation is being made on property that I own which is not
intended for sale, lease, rent, or exchange according to RCW
78.27.090.
Owner S¡gnature
APPTICANT / CONTACT INFORMATION:
Name of Applicant Locken Desioner Homes lnc
Mailing Address:1810 Vernon Road
City/State/Zip:Lake Stevens WA 98258
Phone #:,tà a2Ã,2aÂn
E-mail
GENERAL CONTRACTOR: (lf different from applicant)
General Contractor:
Mailins Address:
City/State/Zip
Phone #:
E-mail
STATE UBI f:An2 n¿1 ÃÃR
CITY OF EDMONDS BUSINESS LICENSE #:NÞ-ñrÂR,l ll
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
o5t02t2021
tr AdditionE Accessory Structure/
Detached Garage
tr Mechanicalfl Demolition
ú Plumbingfl'New Single FamilY / DuPlex
Ll KemooelU Frre 5pnnKler
ú Re-RoofD New CommerciaU Mixed Use
tr Tankt1 Signs
E Other Fe¡ce ..Û Tenant lmProvement
Remodel Permit fees ore bosed on:
The volue of the work performed. lndicote The volue (rounded to
the neoresl dollor) of oll equipmenT, moteriols, lobor, overheod'
ond the profit for the work indicoted on lhis opplicoiion'
Vqluolion:
Finished Ü Unfinished trBasement sq ft:
1st Floor, sq ft:
2nd Floor, sq ft:
Garage/Carport;, sq ft:
Deck/Covered Porch/Patio:
I certify that the information I have provided on this form/application is true'
Other sq ft:
see attached drawing.
New construct¡on home permit number BLD201 801 49 fencinq
Signature:,""zfsfft
TYPE OF PERMIÍ (Provide Detoils on Poge 2)
PROPOSED NEW SAUARE FOOTAGE FOR THIS APPLICATION
PROIECT DESCRIPTION
Occupant Load(s):occupancy Group(s)
tire Sprinklers: Yes I No ÜType(s) of Construction:
WA STATE ENERGY CODE: lf your project
mechanical systems, and/or lighting, you must complete the
forms.
affects the building enveloPe,
appropriate WSEC
DEFERRED SUBMITTALS: All commercial building permits that w¡ll require
associated plumbing, mechanical, fire sprinkler, and/or fire alarm
permits are applied for separately.
Tl / CHANGE OF USE / NEW BLDG: lnclude TRAFFIC IMPACT worksheet
BTUS Gas / Elec / other Qty
A/c Un¡t /compressor
Air Handler /VAV
Boiler
Dryer Duct
Exhaust Fans
Fireplace
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other
atvQtv
Clothes Washer Tub/ Showers
Backflow Device (RPBA, DCEA, AVB)Dishwasher
Pressure Reduction/ Regulatôr ValveDrinking Fountain
Floor Drain/Sink Refrigerator Water Supply
Water Heater - Tankless? Y or NHose Bibs
Hydronic Heat Water Serv¡ce Line
Sinks Other:
Other:Toilets
GENERAL COMMERCIAT DATA
MECHANICAL EQUIPMENT COUNTS (New and Relocated)
PLUMBII\G FIXTURE COUNTS (New, Relocated or re-piped)
BTUS QtyBTUS Qty
outdoor BBQ / F¡re pitA/C Unit
Stove/Range/OvenBoiler
Water HeaterDryer
Other:Fireplace/ lnsert
Other:Furnace
Nitrous OxideCarbon Dioxide
OxygenHelium
Other:Medical Air
Medical - Surgical Vacuum
Type of structure to be demolished:
Other:
Square footage of structure to be demolished:
PSCM Case #AHERA Surveydone? Y/N
Cr¡tical Areas Determination:
Study Required Ê Conditional Waiver E Waiver Ú
Fill in Place fl Fill Material
Size of Tank (Gallons)Removal Ü
Critical Areas Determination:
Study Required I
cubic yardsGrading: Cut
Conditional waiver E Waiver I
cubic yardsFill
Cut / F¡ll in Critical Area: Yes D No E
APPLICATIONS: Applications are valid for a maximum of l year
ESLHA Applications, 2 Years.
LICENSING: All contractors and subcontractors are required to be licensed
with Washington State Department of Labor & lndustries and have a
current City of Edmonds Business License'
GAS/FUEL CONNECTION COUNTS {New, Relocated or re-piped)
MEDICAL GAS, AIR VACUUM COUNTS
(New, Relocated or re-PiPed)
DEMOLITION
TANK
GRADE/FILL/EXCAVATE
GENERAL PROVISIONS
ıVUUTN¡CONTRACTOR IS RESPONSIBLE
FoR ERQSIoN CoNTRÐLA]{D DRAIIIAoE
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